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Psychotherapy
Volume 28/Fall 1991/Number 3
A PSYCHODYNAMIC VIEW OF SIMPLE PHOBIAS AND
PRESCRIPTIVE MATCHING: A COMMENTARY
JACQUES P. BARBER AND LESTER LUBORSKY
University of Pennsylvania
These comments present general
impressions of the articles by Norcross,
Lazarus, Mahrer, Ellis, Beutler and
Prochaska (this issue) and briefly
summarize the essentials of a
psychodynamic approach to the
treatment of phobias. The articles are
then reviewed from a psychotherapy
integration point of view, addressing
the issue whether a danger exists in
matching patients having a specific
disorder to specific treatment. Finally,
we comment on
the
future of matching
patients, disorders, and treatments.
The biggest and most pleasant surprise we en-
countered in reading this set of articles was that,
except for one or two authors (Ellis and perhaps
Lazarus), all contributors seemed willing to con-
sider recommending psychoanalysis or psychoan-
alytically inspired psychotherapy to some patients
presenting with simple phobias. Their reasoning
for such recommendation in some cases seem very
reasonable to us; it follows the wonderful clinical
intuition that different treatments in different cir-
cumstances might be beneficial for different patients
with the same Axis I DSM-HI-R diagnosis.
We would nevertheless agree that, in general,
exposure might be the treatment of choice for
most patients with simple phobias. That is, it is
likely to be the less demanding treatment in terms
of time and money, and in this specific sense of
efficacy, its only rival could be medication. But
efficacy, while a very important issue, especially
Correspondence regarding this article should be addressed
to Jacques P. Barber, Department of Psychiatry, University
of Pennsylvania School of Medicine, Piersol 309, 3600 Spruce
St., Philadelphia, PA 19104-4283.
for insurance companies, is not the sole determinant
of therapy choice. There are patients for whom
this might not
be
the best choice when one considers
their circumstances and other characteristics such
as personality, psychological mindedness, and
values. Even Lazarus (this issue) agrees with the
proposition that treatment addressing only overt
symptoms will, at times, be insufficient. Thus,
he uses his psychodynamic understanding of the
patient to select different stimuli, but still uses
behaviorally oriented techniques for dealing with
these issues.
In these complex cases where a phobic symptom
seems to make a lot of psychodynamic sense, and
the patient is psychologically minded and disin-
clined toward a behavioral treatment, psycho-
dynamicaUy oriented psychotherapy might be the
best choice, i.e., a choice that would satisfy most
of the patients' goals. Lazarus offers the example
of an agoraphobic patient who developed this
symptom to deal with her feelings of being trapped
in her marriage. Psychodynamic therapy as well
as other forms of verbal psychotherapies are likely
to be helpful in improving her relationships with
her spouse, and to find other ways to express her
wishes. In certain circumstances, family therapy
might be the treatment of choice. Again, our view
is that treating a patient presenting with a complaint
that fits the diagnosis of simple phobia with dy-
namic psychotherapy is not necessarily the most
economical treatment of choice, but it might be
the most appropriate.
Treatment of Simple Phobias
Although a wide variety of psychoanalytic psy-
chotherapies exists, our orientation is compatible
with many of them and we believe that most of
our discussion is relevant to most psychoanalyt-
ically derived psychotherapies. As with most other
psychotherapies, treatment recommendations are
derived from the conceptualization and formulation
of the case. It is our impression that patients with
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